Threading the Needle- Coumadin Ridge Papillary Fibroelastomas Complicating Left Atrial Appendage Occlusion

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-9-2025

Abstract

The advancement of transcatheter imaging and intervention has posed the clinical conundrum of increased discovery of incidental masses. We present two unusual cases of incidentally found papillary fibroelastomas (PFEs) along the Coumadin Ridge during left atrial appendage occlusion (LAAO) device planning/placement. These cases highlight the significance of a multi-disciplinary approach in tailoring and executing successful procedural intervention. They additionally emphasize the importance of device selection of LAAO device (e.g. a single-closure mechanism vs a dual-closure disk-and-lobe mechanism) to mitigate risk of interacting with the Coumadin ridge mass and employment cardio-embolic protection devices peri-procedurally.

A 76-year-old female with paroxysmal atrial fibrillation (CHA2DS2-VASc = 7) and recurrent GI bleeding underwent pre-planning transesophageal echocardiography (TEE) for LAAO device consideration to liberate patient from therapeutic anticoagulation. TEE, however, revealed a 0.6cm x 0.1cm mobile mass arising from the Coumadin Ridge, consistent with PFE. Case 2: An 83-year-old male with permanent atrial fibrillation (CHA2DS2-VASc = 5) and recurrent epistaxis was referred for LAAO device placement. Pre-planning TEE noted favorable anatomy, and patient underwent uncomplicated implantation of a 27mm Watchman FLX. Follow-up TEE noted 4mm peri-device leak and a 0.3cm x 0.1cm mobile PFE arising from the Coumadin Ridge that was not seen on pre-procedural nor intra-operative TEE.

An Atrial Fibrillation Heart Team, comprised of electrophysiologists, cardiothoracic surgeons, and advanced imagers reviewed Case 1 and advised pursuing LAAO with cardio-embolic protection device. A SENTINEL Cerebral Protection System (Boston Scientific, Marlborough, Massachusetts) was utilized before a 24mmWatchman FLX (Boston Scientific) was successfully deployed with intra-operative TEE monitoring of PFE. Patient has since been de-escalated to anti-platelet monotherapy with stable appearance of PFE on subsequent monitoring. Case 2 was similarly reviewed by an Atrial Fibrillation Heart Team. Given device leak and patient's age/comorbidities, a decision was made to defer surgical resection for routine monitoring and extension of dual anti-platelet therapy. Subsequent TEE has shown stable findings, even after eventual de-escalation to anti-platelet monotherapy.

The above two cases demonstrate challenging scenarios of unusually located PFEs during LAAO device planning and placement. The presence of such masses impact both procedural and post-implant anticoagulant/antiplatelet regimen planning given the potential embolic nature of these masses. Such cases identify the increasing frequency of incidental intra-cardiac masses as percutaneous procedures rapidly expand and illustrate the success with which a multi-disciplinary approach may navigate such situations.

Comments

2025 Research Day Corewell Health West, Grand Rapids, MI, May 9, 2025. Abstract 1708

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